Interview Request Form

Use this form if you need a clinician or a professional member of our team to answer questions for a media interview.

Please note we are not accommodating interviews for class projects due to high demand for our services.

Make sure to submit the form at least 3 weeks in advance. Requests that are placed after that time frame cannot be guaranteed due to high demand and scheduling logistics.

Name *
Today's Date Today's Date * / MM / DD YYYY
Project Deadline Project Deadline * / MM / DD YYYY

Please note you must submit this form two to three weeks in advance of your deadline. We cannot guarantee an answer otherwise due to high demand for our services. Thank you for your understanding.
Which organization are you affiliated with? *

Which organization are you affiliated with? PantherNow South Florida Media Network (FIU Journalism + Media) FIU External Relations Miami local media (i.e. Miami Herald) SGA Other Other

Please note we are not accommodating interviews for class projects due to high demand for our services.
Which department would you like to contact? *

Which department would you like to contact? Counseling & Psychological Services (CAPS) Victim Empowerment Program (VEP) Dean of Students Office Healthy Living Program Student Conduct and Academic Integrity Student Health Clinics Anyone in Student Health and Wellness
Who are you interested in talking to? *

Who are you interested in talking to? Master's Level Clinician Doctorate Level Clinician Director Front Desk Staff Health Educator Anyone belonging to the department Other Other
Interview Questions (Please make sure these are not already being answered by a visit to our website shw.fiu.edu) *

Due to high demand and scheduling purposes we ask that you send us the questions ahead of time.
Does your interview need to be recorded? (Please note this may affect the viability of the interview) *

Does your interview need to be recorded? (Please note this may affect the viability of the interview) Yes No
Can your interview be facilitated by: *

Can your interview be facilitated by: Phone Email In person Videoconferencing Any of the above
Your Phone Number: Your Phone Number: - ### - ### ####
Your Email Address (We will confirm the viability of the interview only by e-mail): *
Availability *

Please provide us with several dates and times when you could be reached by our staff.
Please provide us with any other information you would like us to have (if applicable):